St. Agnes Healthcare and Rehab Center

Inspectors wroteBased on interviews and record reviews, the facility failed to identify and correct situations that could possibly result in actual or suspected abuse by failing to immediately report a complaint made by a resident to the Administrator or designee for 1 (#92) resident out of 30 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received an assistive device to maintain and/or improve hearing for 1 (Resident #6) out of 1 resident investigated for communication-sensory.

Inspectors wroteBased on observations, interview, and record review, the facility failed to store food in accordance with professional standards for food service and failed to ensure sanitary conditions were maintained in the kitchen by failing to:Appropriately store, label and date frozen food items, and Ensure kitchen staff used good hygienic practices while preparing and serving food to residents. This had the potential to affect 93 residents who consumed foods from the facility's kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's plan of care was implemented as ordered for 2 (Resident #3, Resident #7) out of a total sample of 30 residents by failing to:follow physician's order for assessing Resident #3's dialysis site; andfollow physician's order for monitoring of right hand splint; administering enteral feed; and administering enteral flush for Resident #7.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a resident's care plan was accurately updated to reflect the resident's current code status for 1 (Resident #3) out of 30 sampled residents. This deficient practice had the potential to affect a total census of 95 residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure: 1. food was dated after opening; and 2. food was properly sealed and stored. The facility had a census of 95 residents.

Inspectors wroteBased on observations, interviews and infection policy review, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections as evidenced by failing to: 1. Appropriately handle and transfer soiled laundry; 2. perform proper hand hygiene; 3. appropriately remove PPE (Personal protective equipment); and 4. sanitize dirty scissors before re-using.

Inspectors wroteBased on observations, interviews and record review the facility failed to assess 1(#12) out of 1 sampled residents for self-administration of medication in a final sample of 35 residents.

Inspectors wroteBased on record review, policy review and interviews, the facility failed to report to the administrator of the facility a resident report of sexual abuse for 1(#85) of 1 resident sampled for abuse. This had the potential to affect the 95 residents that reside in the facility.

Inspectors wroteBased on record review and interview, the facility failed to follow the care plan for Resident #80 as evidenced by failing to offer the resident a visit with the in house dental consultant for 1 (#80) out of 35 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that services were provided to meet professional standards of quality as evidenced by S13TN (Treatment Nurse) leaving medication at the bedside for 1 (#12) out of 1 resident, who was not assessed for self-administration of his medication, out of a total sample of 35 residents. This deficient practice had the potential to affect the 95 residents in the nursing home.

Inspectors wroteBased on record review and interview, the facility failed to ensure that staffing data posted daily included resident census and total number of hours worked.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure all drugs and biologicals were stored in locked compartments as evidenced by the nurse leaving the medication cart unlocked and unattended during the medication pass on Hall B.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that certified nursing aides (CNAs) who transported residents in the facility's van were trained and competent on the proper and safe procedure for securing the resident's wheelchair in the van according to the manufacturer's instructions. This deficient practice was evidenced by 1 (S2TransportationCNA) of 2 transportation CNAs observed improperly securing Resident R1 in the facility's transportation van.

Inspectors wroteBased on record review and interview, the facility failed to ensure that all alleged violations of abuse were reported immediately to the administrative staff for 2 (#1 and #2) out of 3 (#1, #2, and #3) sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, clean, and homelike environment as evidenced by failing to complete maintenance rounds to identify and repair the following: 1. Resident # 21's Chest of Drawer was broken 2. Resident # 63's bathroom toilet paper dispenser was broken 3. Resident # 19's bathroom toilet was loose 4. Resident # 250's headboard was loose and not working properly 5. Residents # 9, # 57, and # 93's hot water faucet produced only cold water

Inspectors wroteBased on record review and interview, the facility failed to refer residents who had a qualifying diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (Resident #70) of 1 resident sampled for PASARR. The deficient practice had the potential to affect a total census of 99.

Inspectors wroteBased on record review and interviews, the facility failed to ensure an alleged violation of abuse was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1 (#21) out of 2 (#21 and #94) residents investigated for abuse.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to identify and provide resident centered care and services in order to attain the highest practicable well-being for 1 (# 200) resident out of a finalized sample of 44 residents. This deficient practice was evidenced when the facility's staff failed to accommodate Resident # 200's smoking preference while he was on Contact isolation precautions.

Inspectors wroteBased on observations and interviews the facility failed to properly store respiratory equipment for 1 resident (#57) out of 3 residents (#91, #10, and #57) investigated for respiratory care.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Registered Nurse (RN) provided services for 8 consecutive hours a day, 7 days a week for 4 of 14 days reviewed for RN hours.

Inspectors wroteBased on record review and interview, the facility's staff failed to notify the resident's representative of a change in the resident's condition by failing to: 1. Immediately inform the resident's (#1) representative that the resident was admitted inpatient to the hospital for urinary tract infection; and failing to; 2. Immediately inform the resident's (#3) representative of the residents return to the facility from the hospital for 1 ( #3) out of 4 sampled residents. This deficient practice has the potential to affect all the residents residing in the nursing facility. The total census was 100.

Inspectors wroteBased on an observation, record reviews and interviews, the facility failed to ensure nursing staff demonstrated competencies to provide care, assure residents' safety, and maintain the residents' highest practicable physical well-being. The facility failed to assure the facility failed to assure that each resident received an accurate assessment by failing to: 1. Complete an accurate weekly skin assessment/body audit for 1 (Resident #1) of 4 (#1, #2, #3, #4) residents sampled for weekly body audits, and 2. Complete a readmit assessment for Resident #3 after returning to the facility from the hospital on [DATE].